Health Care Ethics, Fall 1997

MEDICAL ETHICS: IN NEED OF REPAIR?

For years medicine has proudly stated that service to the patient and altruism are the basis of its ethics. But is this assumption still true? Has the nature of providing medical care so changed in the past few years that a new ethic must be developed? Have managed care and investor-owned health care corporations modified the ethics of medicine so that the traditional ethics must be radically revised? This essay will consider these questions, at the same time seeking to update and offer a suggestion for preserving medical ethics.

Principles

The source of medical ethics from ancient times is the physician-patient relationship. The physician promises to help the patient strive for health. While the patient will remunerate the physician in order to provide the means to continue the practice of medicine, the ultimate goal of the physician-patient relationship is the well-being of the patient, not the enrichment of the physician. The ethical standards of medicine have been summed up by describing medicine as one of the classical professions. Most contemporary professions such as engineering and accounting help people to a better life, but they are not professions in the classical sense because they do not help people become better persons. Their immediate objective is productive, not personal. Medicine, along with law, education and ministry, qualifies as a profession in the classical sense of the term because:

  1. It seeks to improve a person qua person.

  2. In order to help a patient as person, all the functions of the person must be understood and respected; in other words, the patient must be known as an individual.

The close personal relationship of physician and patient demands trust as an indispensable condition. This is the principal reason why money must not be the ultimate goal of medical care. Nothing will destroy the development of trust as the realization that physicians are more interested in money than in the well-being of their patients. Trust, service and altruism have been incorporated into oaths and ethical codes for physicians. The most famous oath of this value is the Hippocratic Oath. While the Hippocratic Oath is worthwhile as far as it goes, it really doesn't go far enough. (1) The Hippocratic Oath embodies well-being for the patient as the ultimate cause of medical care, and it calls for confidentiality and respect of the person but it fails to mention two ethical norms that are necessary in contemporary medical practice. Specifically, it does not emphasize the need for competence on the part of the physician nor the need for physicians to be concerned with needs of the community as well as the needs of individual patients.

Competence is defined by Jonson as:

"The ethics of competence, fully understood as mastery of the science and skills of diagnosis, therapy and prevention of disease, together with an appreciation of the personal and social aspects of the patient's health and disease, are the glory of modern medicine. They are the standard to which all physicians must be held -- the goal of medical education and the expectation of the public. " (2)

Hence, competence requires that physicians acquire scientific knowledge to the highest degree possible and that they are all to apply this knowledge.

Meeting the needs of the community has added other responsibilities to those originally included in the Hippocratic Oath. The Oath requires that the social function of the individual must be respected by health care professionals. The needs of a family, for example, will often influence the choice of treatment of a particular patient, especially at times of serious illness or impending death. Does Mom want to be sustained in her last days by a respirator which would impede communication with the family, or does she wish to allow death to ensue without the respirator because this form of therapy impairs her social function. Thus, the traditional medical ethics recognized the social needs of patients.

But the challenge of social justice is much more extensive than the responsibility to be aware of the social needs of singular persons. The challenge of social justice to the health care professionals is a concern for the health care of society qua society. Thus, health care professionals must be concerned with general programs to prevent disease and with the provision of health care for all. Pellegrino aptly expresses this new challenge:

"The physician js sense of responsibility toward his patient is one of the most admirable features of medicine and must always remain the central ethical imperative in medical transactions. But, it must now be set in a context entirely alien to that in which ancient medicine was practiced. In earlier eras, the remote effects of medical acts were of little concern, and the rights of the individual patient could be the exclusive and absolute base of the physician's actions. Today, the growing interdependence of all humans and the effectiveness of medical techniques have drastically altered the simplistic arrangements of the traditional ethics..." (3)

Social justice requires a recognition that the common good must be the concern of every profession and business enterprise in a true community, profit, prestige and power being of lower priority than the common good. In the United States, if people recognize ethical responsibilities at all, they are usually so influenced by individualism that they shy away from responding to the needs of others. Being devoted to the common good is not a form of socialism. Promoting the common good promotes the good of individuals but in an equitable manner. Working for the common good insofar as health care is concerned is a responsibility of all the people in our nation, but health care professionals bear the brunt of the responsibility because of their prominence in the field. The best way to conceive of this added responsibility is to realize that fulfilling personal and social standards of ethical health care is not a matter of "either - or," rather it is a matter of "both - and." Hence, realizing the need for health care professionals to broaden their ethical vision to include the common good does not imply neglect of individual needs. The common good is designed to help individuals fulfill their personal goals. If physicians as a profession fail to recognize this responsibility, their profession will be considered nothing more than another method of manipulating the public.

Discussion

Has traditional medical ethics changed? Not in its basic principles; the essence of medicine still demands a personal relationship based upon trust and the commitment on the part of practitioners to the well-being of patients. Managed care has not mitigated this responsibility. However, the scope of medical ethics has been broadened. Competence and social responsibility are now integral parts of the physician's creed. How can the blend of classical and modern ethical norms be preserved? When Mahatma Gandhi was asked if he could make people good, he replied: "No, but it is possible to create conditions in which it is easier to choose good." With this in mind, I believe the leaders of medicine must seek to emphasize the ethics of medicine as a unifying goal. Living the ethics of medicine will give medicine its meaning and fulfillment. While the officials of the AMA or the National Institutes of Health are often considered the leaders of the medical profession, I believe that the VP's, deans, and chairs in medical schools are much more influential. They create the culture of medicine. If these persons insist decisively that ethics is at the heart of medical education, residency and practice, then the continuance of medicine as a classical profession is possible. Certainly the type of emphasis I suggest requires more than deference to the Hippocratic Oath at the time of graduation. It will require a consistent emphasis upon the specific ethical stanards mentioned above. Because of its emphasis upon competence, the traditional ethics is not soft science; rather it requires a comprehensive knowledge of human physiology and psychology and the techniques to apply this knowledge effectively.

Conclusion

Fifteen years ago, a popular book entitled In Search of Excellence sought to determine why some business organizations are more suecessful than others. The results of the study:

"Determine your value system and make the sharing of these values your highest priority." Fortunately, medicine has definite and clear values. But are these values emphasized sufficiently?

Kevin O'Rourke, OP

Footnotes

1. Trotter, G., The Loyal Physician, Roycean Ethics and the Practice of Medicine, (Nashville, TN: Vanderbilt University Press, 1997), 34ff.

2. Jonson,A., The New Medicine and the Old Ethics, (Cambridge: Harvard University Press, 1990), 27.

3. Pellegrino, E., Humanism and the Physician, (Knoxville, TN: University of Tennessee Press, ]979), 103.

Suggested Readings:

Questions for Discussion:

1. Can the traditional ethics of medical care survive in a for-profit investor-owned health care corporation?

2. What specific procedures might be employed in your institution to preserve the traditional ethics of medicine?

3. Is the ultimate purpose of business to make a profit, or to contribute to the common good?

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© Kevin O'Rourke, O.P.